Oct. 24, 2013

Scott Modell / Larry McCormack / The Tennessean

Written by

Walter F. Roche Jr.

The Tennessean

Internal records and investigative reports on the deaths of two disabled patients under state care show that state investigators concluded there was clear evidence both were victims of neglect, despite the decision of a top state official to overrule them.

The extensive reports obtained by The Tennessean provide more in-depth details after Monday’s state comptroller report, which concluded that the state official, Scott Modell, exceeded his legal authority in reversing the neglect findings.

The redacted reports show that state investigators found two staffers of the Behavioral Services of Tennessee, based in Cordova, were negligent in their care of a female patient who choked on a burrito that had not been properly cut into bite-sized portions.

The unnamed patient was rushed to a hospital and revived, but she was declared brain-dead and died in late January of last year.

In the second case, a male patient was found dead from a drug overdose while under the care of the same Shelby County provider. Though a medical examiner later concluded it was a case of suicide, the state investigators said three staffers and the provider were guilty of neglect for failing to act on the man’s clearly deteriorating condition in the days and weeks before his Aug. 3, 2011, death.

Modell, who the comptroller’s report said reversed neglect findings in both cases, was a deputy commissioner in the Department of Intellectual and Developmental Disabilities at the time. Since then, he has transferred — along with his boss, Jim Henry — to the Department of Children’s Services, where Henry is commissioner and Modell heads the patient safety unit.

Modell said earlier this week that he thought he did have the legal authority to reverse the investigative findings.

The 2 cases

The data on the two deaths were released just hours after DIDD officials assured legislators that procedures had been put in place to ensure that such reversals would not be repeated.

In the case of the female patient, the patient records and the subsequent investigative report show that the burrito on which she choked had not been diced small enough for each piece to fit into a teaspoon.

The worker “failed to follow the meal safety precautions on which she had been trained,” the report of an investigative committee concluded.

Her supervisor, the panel concluded from videotapes of the incident, had the opportunity to see the condition of the food, “yet she failed to intervene.”

The two staffers were sitting right next to the victim on Jan. 18, 2012, when she suddenly stood up gasping for breath. Resuscitation efforts failed as the patient fell to the floor. She was rushed to a nearby hospital but was declared dead on Jan. 24, 2012, according to the reports.

The supervisor was cleared of one charge of neglect because she was not involved in the food preparation. But she was found guilty by investigators of neglect for failing to follow mealtime guidelines.

The records released show that five days later Modell reversed the finding of neglect by the supervisor but apparently left in place the finding against the aide who prepared the food.

In the second case, investigators had concluded that three staffers and the facility operator were guilty of neglect for failing to take action when a male patient became increasingly unresponsive.

The investigative report showed there were conflicting statements about the patient’s condition, and questions were raised about the possibility that he had been hoarding powerful antipsychotic drugs, including Haldol, which may have made possible a suicide attempt.

The medical examiner’s report concluded that the cause of death was “combined drug toxicity” and the manner was suicide.

While the investigators concluded that three staffers and the facility itself were guilty of neglect, an addendum to the reports concluded that while the actions of two of the staffers and the facility management “were not the most appropriate on Aug. 3, 2011, they did not rise to the level of neglect.”

Unlike in the other case, however, the records released on the male patient do not show exactly what role Modell played in the handling of the case.